Assistive Devices Subsidy Application Form (Outreach) MND Complex Annex B 7 Maxwell Road #04-01 Singapore 069111 Email: smf.community@aic.sg Call: 1800-650-6060 Website: www.silverpages.sg ELIGIBILITY CRITERIA The Seniors Mobility & Enabling Fund (SMF) provides holistic support for seniors to age in place within the community by extending subsidies to Singaporean seniors. Please use this form to apply for subsidies for assistive devices only. For application of home healthcare items, please approach your home healthcare provider. To be eligible for SMF assistive devices subsidy, you must: Be a Singapore Citizen aged 60 and above Have a household monthly income per person of $1,800 and below OR an Annual Value (AV) of residence reflected on NRIC of $13,000 and below for households with no income Have no previous application for the same assistive device category under SMF Be assessed by a qualified assessor on the type of device required Be able to co-pay for the assistive device INSTRUCTIONS TO APPLICANT 1. Please make sure that you meet the above scheme eligibility criteria before completing this form. 2. This application will take about 10 minutes to complete. 3. Please tick accordingly, and complete all fields of the application form. The information provided must be accurate as of the date of submission. Application will be processed upon receiving complete set of documents from you. 4. Your submission to AIC should include the following: i. Completed application form ii. Copy of Applicant s NRIC (Front and Back) iii. Medical reports if available (e.g. Discharge summary, doctor s memo describing applicant s medical condition) and/or iv. Financial assistance documents if available (e.g. Public Assistance Card, Medifund, Medical Fee Exemption Card or MSF ComCare Shortto-Medium Term Assistance) 5. You may submit your application through: Email: smf.community@aic.sg Post: MND Complex, Annex B, 7 Maxwell Road, #04-01, Singapore 069111 Walk-in: AICareLink located at various locations. To find an AICare Link near you, visit https://www.silverpages.sg/aicarelink/ 6. This application is subjected to the terms and conditions of the SMF assistive devices subsidy which can be found in Annex A. By signing and/or affixing your thumbprint, you acknowledge to have read and accepted the terms and conditions governing the scheme. 7. AIC may contact you for further clarifications on your application, if any. SMF Assistive Devices Subsidy Application Form (Outreach) Version 2 Effective: 1 April 2018 Page 1 of 3
Assistive Devices Subsidy Application Form (Outreach) MND Complex Annex B 7 Maxwell Road #04-01 Singapore 069111 Email: smf.community@aic.sg Call: 1800-650-6060 Website: www.silverpages.sg Name (as per NRIC): NRIC No.: Race: Chinese Malay Indian Others: Date of Birth (DD/MM/YYYY): Contact Number (Home/Mobile): Gender: Male Female Address (as per NRIC): Unit No.: PART 1A: PARTICULARS OF APPLICANT / / / Postal Code: Age: PART 1B: PARTICULARS OF NEXT OF KIN / CONTACT PERSON Name (as per NRIC): Relationship to Applicant: Contact Number: (Home/Mobile) PART 1C: DEVICE CATEGORY TO BE ASSESSED (a) Walking Aids (f) Pressure Relief Mattress (b) Wheelchair/ Pushchair (g) Special Equipment (e.g. Hoist, Transfer Board, Transfer Belt) (c) Pressure Relief Cushion (h) Geriatric Chair By signing and/or affixing my thumbprint, I acknowledge to have read and accepted the Declaration, Consent for Disclosure and use of Personal Information as well as Terms and Conditions found in Annex A. I am aware that I would need to bear the 10% co-payment of the prescribed assistive device(s) and any excess amount. Failure to do so would affect the supply of the device. *Signature/Thumbprint of Applicant & Date (d) Commode Spectacles Please register for next Functional Screening Event in your neighbourhood (e) Hospital Bed *Signature/Thumbprint of Next of Kin/ Contact Person & Date (if applicable) Hearing Aids Please obtain referral letter from polyclinic for hearing assessment at the public hospital. *For applicant who lacks mental capacity, his/her signature is not required. His/her next-of-kin/contact person must sign on his/her behalf. SMF Assistive Devices Subsidy Application Form (Outreach) Version 2 Effective: 1 April 2018 Page 2 of 3
Assistive Devices Subsidy Application Form (Outreach) MND Complex Annex B 7 Maxwell Road #04-01 Singapore 069111 Email: smf.community@aic.sg Call: 1800-650-6060 Website: www.silverpages.sg PART 2: MEDICAL DECLARATION BY APPLICANT 1. Do you have a medical appointment at any hospital in the next 3 months? No Yes (If Yes, please provide following information) Name of Hospital: Date of Next Follow-up Appointment: (DD/MM/YY) Appointment Type: Rehab Blood/Medical Tests See Doctor 2. Are you receiving any centre-based or home based services (e.g. Rehabilitation, Day-Care Services)? No Yes (Please provide name of centre) Name of Centre: 3. For the safety of the assessor and the community, please let us know if you have/recently had any infectious diseases. Steps to control the infection will be taken by our assessors. No Yes, Please tick the type of diseases: Pulmonary Tuberculosis (TB) Chicken Pox / Shingles Others: Date of onset of disease: (DD/MM/YY) Date of last follow up at the hospital: (DD/MM/YY) 4. Select the type of mobility aid that applicant is currently using: No Mobility Aid Walking Stick Quadstick Walking Frame Rollator Frame Wheelchair / Pushchair Others: SMF Assistive Devices Subsidy Application Form (Outreach) Version 2 Effective: 1 April 2018 Page 3 of 3
BLANK SMF Assistive Devices Subsidy Application Form (Outreach) Version 2 Effective: 1 April 2018
SMF Assistive Devices Category List This copy is to be kept by the Applicant for reference. ASSISTIVE DEVICE CATEGORIES (a) Walking Aids (b) Wheelchair / Pushchair (c) Pressure Relief Cushion (d) Commode (e) Hospital Bed (f) Pressure Relief Mattress (g) Special Equipment (e.g. hoist, transfer board) (h) Geriatric Chair Note: All pictures are for illustration purposes only. The actual device may differ from pictures.
SMF Assistive Devices Subsidy Terms and Conditions This copy is to be kept by the Applicant for reference. ANNEX A TERMS AND CONDITIONS DECLARATION 1. I affirm that all the information provided in my application for subsidy which includes all the documents submitted, is true and correct to the best of my knowledge, and I have not deliberately omitted any necessary information relevant to this application. 2. I am aware that Agency for Integrated Care ( AIC ) has the right to recover the SMF subsidy given to me, if I do not pass the Means-Test criteria, have provided inaccurate information, or withheld any relevant information from the Qualified Assessor 1 and/or administration staff of the Organisation administering the SMF scheme. 3. I will fully indemnify AIC, the Organisation administering the scheme and the Government of the Republic of Singapore against any loss, damage, cost and expense whatsoever, including any legal cost on a full indemnity basis, which may be incurred by AIC, the Organisation administering the scheme and the Government of the Republic of Singapore as a result of any false or inaccurate information given by me or my failure to comply with my obligations. 4. I have read and understood all the terms and conditions of my application and agree to be bound by them. 5. I agree to abide by AIC s decision regarding my application, which is final. CONSENT FOR DISCLOSURE AND USE OF PERSONAL INFORMATION 6. I understand that the sharing of Personal Information 2 between different entities such as the Government, and certain participating statutory boards and organisations approved by the Government, will assist in the evaluation of my suitability and eligibility for SMF Scheme. 7. I agree that any Cooperating Party 3 may: a. collect my Personal Information from me or any of the other Cooperating Parties; b. disclose my Personal Information to any of the other Cooperating Parties; and c. use my Personal Information regardless of whether my Personal Information relates to matters occurring before, on or after the date of this consent, for the purposes of: a. evaluating my suitability and eligibility for SMF Scheme at any time; b. the administration and provision of SMF Scheme in relation to me; and/or c. data analysis, evaluation and policy formulation, in which I shall not be identified as specific individuals or households (collectively known as the Purpose ). 8. I consent to AIC and/or and the Organisation administering the SMF scheme in obtaining the applicant s medical information from any healthcare professional who is providing or has provided medical care, treatment to, or has medically assessed the senior. 9. This consent shall be governed by and construed in accordance with the laws of the Republic of Singapore. TERMS AND CONDITIONS APPLICABLE FOR SMF ASSISTIVE DEVICES SUBSIDY APPLICATION 10. I affirm to my best knowledge that this is my first application for the device category and I have not received any previous SMF funding in the same device category. 11. I allow AIC and/or the Organisation administering the SMF scheme to access my Means Test result from the National Means Test System for the purpose of this application. 12. I will not hold AIC and/or the Organisation administering the SMF scheme liable if my Means Test result has expired and I am unable to qualify for the SMF subsidy. 13. I have been briefed by AIC and/or the Organisation administering the SMF scheme and will be expected to make the required co-payment after the SMF subsidy. 14. I agree that neither AIC and/ or the Organisation administering the SMF scheme nor the assistive devices vendors are responsible for replacement, repair and/or maintenance of the assistive devices issued to me. 15. I will not hold AIC, the Organisation administering the SMF scheme or any related assessors for accidents and/or incidents related to the use of the assistive devices issued and for the duration of the client education session provided. 1 Qualified Assessor is in accordance to SMF Qualified Assessor List, and subjected to the type of device prescribed. This includes fully registered physiotherapists, fully registered occupational therapists, registered nurses, registered doctors, certified audiologists, fully registered optometrists, centre managers and SMF personnel trained in administering the Simplified Assessment Tool. 2 Personal Information means an individual s personal data (e.g. name, NRIC No, address, age, gender, family/household structure), financial data (e.g. income, savings, insurance coverage), consumption data (e.g. payment for utilities, housing, healthcare bills, scheme participation), social assistance data (e.g. social assistance history, assessments for eligibility and suitability for various Services and Schemes, social worker case reports) or medical information, that is relevant for the purpose of this application. 3 Cooperating Parties shall refer to the Government of the Republic of Singapore (the Government ), and participating statutory boards and organisations approved by the Government, including AIC and the approved organisations that are involved in or assisting in the provision and delivery of the SMF Scheme.